Anatomy of knee joint OSTEOARTHRITIS - PowerPoint Presentation

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Anatomy of knee joint

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OSTEOARTHRITIS

The knee is the commonest of the large joints to be affected by osteoarthritis .Often there is a predisposing factor(secondary): injury to the articular

surface, a torn meniscus, ligamentous instability or preexisting deformity of the hip or knee, to mention a few. However, in many cases no obvious cause can be found (primary).

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RISK FACTOR

genetic component. Curiously, while the male:female distribution is more or less equal in white (Caucasian).peoples, black African women are affected far more frequently than their male counterparts.

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Pathology

1-Cartilage breakdown usually starts in an area of excessive loading.2-changes are most marked in the medial compartment

narowing of joint space.(varus

)

3- sclerosis of the

subchondral

bone and peripheral

osteophyte

formation

Chondrocalcinosis

is common.

4-

capscular

fibrosis.

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PATHOLOGY OF OA

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Clinical features

Age :Patients are usually over 50 years old; they tend to be overweight and may have longstanding bow-leg deformity.

Pain is the leading symptom, worse after use, or on stairs. After rest, the joint feels stiff and it hurts to ‘get going’ after sitting for any length of time. Swelling is common, and giving way or locking may occur.

On examination

there may be an obvious

deformity (usually

varus

) or the scar of a previous operation. The quadriceps muscle is usually

wasted.

Except during an exacerbation, there is little fluid and no warmth; nor is the synovial membrane thickened

(effusion).

Movement is somewhat limited and is often accompanied by

patello

-femoral

crepitus

.

The natural history of osteoarthritis is one of alternating

‘bad spells’ and ‘good spells’.

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X-ray

The anteroposterior x-ray must be obtained with the patient standing and bearing weight; only in this way can small degrees of

articular cartilage thinning be revealed. 1-The tibio-femoral joint space is diminished(often only in one compartment) and there is

2-subchondral sclerosis.

3-Osteophytes and

4-

subchondral

cysts

5-chondrocalcinosis are usually present and sometimes there is soft-tissue calcification in the

suprapatellar

region or in the joint

itself

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X-ray

Non weight bearing

X-ray weight bearin

g

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Treatment

A-CONSERVATIVE TREATMENT:

1-Joint loading is lessened by using a walking stick.2-Quadriceps exercises are important.3-Analgesia like NSAIDs .

4-physiotherapy like heat ( short wave or infrared therapy) ,message ..etc.

5-A simple elastic support may do wonders, probably by improving

proprioception

in an unstable knee.

6-Intra-articular corticosteroid injections will often relieve pain, but this is for short duration.

7-intra

articular

intra-

articular

injection of

hyalouranic

acid or platelet rich plasma is anew modalities with oral of glucosamine.

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OPERATIVE TREATMENT

Persistent pain unresponsive to conservative treatment, progressive deformity and instability are the usual indications for operative treatment:-

1-Arthroscopic washouts, with trimming of degenerate meniscal tissue and osteophytes, may give temporary relief.

2-

Realignment

osteotomy

is often successful in relieving

symptoms and staving off the need for ‘end-stage’ surgery. The ideal indication is a ‘young’ patient

(under 50 years) with a

varus

knee and osteoarthritis

confined to the medial compartment: a high

tibial

valgus

Osteotomy

.

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3-Replacement

arthroplasty is indicated in olderpatients with progressive joint destruction. This isusually a ‘resurfacing’ procedure, with a

metalfemoral condylar component and a metal-backed polyethylene table on the tibial side.

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Lesions of the menisci

Meniscal tears

The menisci have arole in(1)increase the stability of the knee,(2)controlling the complex rolling and gliding actions of the joint and(3)distribution load during movement.

Tears are common in young

adults

,it

split in its length by

aforce

grinding it between the femur and the

tibia,this

occur when weight is being taken on the flexed knee and there is twisting strain in young (

footballers

).

Medial meniscus is affected more than lateral because its attachments to the capsule make it less mobile.

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Acute tears are often related to trauma, most frequently as a result of a twisting motion.

Most common in active people aged 10–45.

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Anatomy of meniscus

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Types of tears :-

1-Vertical tears like

(a)bucket-handle tears when split vertical but still attached anterioly and posteriorly;(b)anterior or posterior horn tears

when

afree

fragment remains attached

anteriorly

or

posteriorly

.

2-Horizontal tears

are usually degenerative or due to repetitive minor trauma ,may be associated with

meniscal

cysts.

Most of meniscus is

avascular

and spontaneous repair does not occur unless the tear is in outer third which is

vascularized

from the capsule. The loose tags act

as

amechanical

irritant,which

give rise to

recurrent

synovitis

,effusion and secondary osteoarthritis .

 

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Meniscal tears

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Clinical features:-

The patient is young age with history of twisting injury to the knee on sport field. Pain is severe and occasionally the knee is

locked in partial flexion; swelling some hours later.With rest the initial symptoms subside and recur after trivial strains or

twists;sometimes

the knee

gives way

and again followed by pain and swelling.

If the patient is over 40 with no history of

trauma,the

main complaint is of recurrent giving way or locking.

Locking is a sudden inability to extend the knee fully suggests

abucket

-handle tear

.

On examination

; the joint may be held slightly flexed and

effusion,tenderness

localized to the joint line on medial

side;later

on there's

wasting

of the quadriceps ;

Apley's

grinding test

may be positive.

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Imaging :-

Plain x-ray are normal but MRI are reliable method for diagnosis that are missed by arthroscopy .Arthroscopy :-

It has advantage that if a lesion is identified ,it can be treated as the same time . Treatment :-

In the past,

meniscal

tears were treated by

open

operation

;

nowadays

arthroscopic surgery

is preferable.

For the peripheral

tears,operative

repair is feasible otherwise displaced portion should be

excised(partial or complete

meniscectomy

).

postoerative

physiotherapy is an important part of the treatment.

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Investigation

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Meniscal

cystsA

meniscal cyst can be likened to ganglion because it contain gelateneous fluid and surrounded by fibrous tissue.Its probably traumatic in origin, arising from either asmall

horizontal tear or repeated squashing of the peripheral part of the meniscus.

The patient presents with pain, and a small lump can be seen and

felt,usually

on the lateral side of the

joint;it

may feel firm or tense particularly when the knee is extended.

If it's

symptomatic,the

cyst can be decompressed or removed

arthroscopically;any

meniscal

lesion can be dealt with same time.

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Knee deformity :-Bow legs(Genu varum

)and Knock knees(Genu valgum

)

BY the end of growth, the knees are normally in 5-7 degrees of

valgus,so

any thing more or less than that would be classified as deformity.

In

general,deformity

is usually can be noticed by simple

observation,this

is best done with the

Bilateral

genu

varum

(bow leg)

can be recorded by measuring the distance between the knees with the legs straight and the medial

malleoli

just

touching;it

should be less than 6 cm.

Genu

valgum

(knock knee)

can be recorded by measuring the distance between the medial

malleoli

when the knees are held touching with patellae facing

forwards;it

is usually less than 8 cm.

patient standing and bearing weight.

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Genu

varum and valgum

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In children

these deformities are so common that are consarsidered normal stages of development,most

correct spontaneously by the age of 10-12.Treatment is unnecessary but reassured the parents and the child should be seen at intervals of 6months to record progress.If the deformity is still

marked,by

the

ageof

10 years so

operative correction

is needed by:-

1-stapling one side of the

physis

to slow growth on that side(

epipheseodesis

). 2-

osteotomy

,at a later stage.

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Bone

dysplasias and rickets

are associated with more intractable deformities which needed operative correction.Blount's disease is aprogressive bow leg deformity associated with abnormal growth of the

posteromedial

part of the proximal tibia, children are often overweight and start walking

early;deformity

is usually bilateral and rotational element.

ethe

epiphysis.spontaneous

resolution is rare and operative correction is usually needed.

Valgus

and

varus

deformities in adults

–

especially if they are unilateral are likely due to

rheumatoied

arthritis(

valgus

) or osteoarthritis(

varus

).

Treatment

:slight deformity can be well tolerated but if the deformity is marked or associated with

instability,it

can be corrected by joint reconstruction or

supracondylar

femoral

osteotomy

for

valgus

and high

tibial

osteotomy

for

varus

.

 

 

 

 

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Osteochondritis

(Osteochondrosis

)  Its agroup

of conditions in which there is

compression,fragmentation

or separation of small segment of

articular

cartilage and bone ,there's

afeatures

of ischemic necrosis with death of bone cells and reactive

vascularity

and

osteogenesis

in the surrounding

bone;despite

the

name,there

are no signs of inflammation.

It occurs mainly in adolescents and young adults

Causes:-

It occurs during phases of increased physical activity and may be initiated by trauma or repetitive stress ,however there's other predisposing factors(multifocal or familial)

Ther

are three types of

Osteochondritis

:-

1-crushing

Osteochondritis

.

2-splitting

Osteochondritis

(

Osteochondritis

dissecans

).

3-pulling

osteochondritis

(traction

Osteochondritis

).

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Crushing

Osteochondritis

  it's characterized by spontaneous necrosis of the ossific nucleus in long bone epiphesis

or one of the

cuboidal

bones of the wrist or foot.

The pathological changes are the same as those in other forms of

osteonecrosis

: bone

death,fragmentation

or distortion of the necrotic segment and reactive new bone formation around the ischemic

trabeculae

. 

Clinical features :

Pain

and limitation of joint movement are the usual complaints.

Tenderness

is sharply localized to the affected

bone

.X

-rays

show the characteristic increased

density,accompanied

in the later stages by distortion and collapse of the necrotic segment.

Examples of crushing

Osteochondritis

are Freiberg's diseases of the metatarsal ; Kohler's disease of the

navicular

;

Kienbock's

disease of the carpal

lunate

;

Panner's

disease of the

capitulum

and

Scheuermann's

disease (vertebral

Osteochondritis

)

.

Treatment is conservative(analgesia and

splintage

) rarely need operation

.

 

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splitting

Osteochondritis(

Osteochondritis dissecans)

 

a small segment of

articular

cartilage and the subjacent bone may separate(dissect) as an

avascular

fragment.it

occur typically in young adults usually men and affects particular sites:

the lateral surface of the medial femoral

condyle

in the knee , the

anteromedial

corner of the talus , the

superomedial

part of the femoral head , the humeral

capitulum

and the first metatarsal head.

The cause is almost certainly repeated minor trauma resulting in

osteochondral

fracture of a convex

surface;the

fragment loses its blood supply.

The knee is the commonest joint to be affected with intermittent

pain,swelling,joint

effusion,locking

of the joint and giving way

.

X-rays

show the dissecting fragment is defined by the radiolucent line of the

demarcation,when

it

separates,the

resulting (crater).

The early changes are better shown by

MRI

;there's

decreased signal intensity in the area of the affected

osteochondral

segment.

Radionuclide scanning with 99mTc-HDP

show markedly increased activity in the same area.

 

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Treatment

in the early stage consist of load reduction and restriction of the activity. In children,complete healing may occur(up to 2 years).

In adult,it is doubtful,however it is generally recommended that partially detached fragments are pinned back in position(by arthroscopy in the knee joint), if the fragment becomes detached and causes symptoms ,it should be fixed back in position or else completely removed .

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pulling

osteochondritis(traction

Osteochondritis) there's localized pain and increased radiographic density in an unfused

apophysis

may result from tensile stress on the

physeal

junction.

Ther

are two sites:

tibial

tuberosity

(Osgood-

Schlatter's

disease)and the

calcaneal

apophysis

(

Sever's

disease);

both are subject to unusual traction forces from powerful tendons which insert into the

apophysis

junction .

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Osgood-

Schlatter Disease

 Osgood-Schlatter (OS) disease is more appropriately described as a disorder or a condition. Osgood, in the English literature, and

Schlatter

, in the German literature.

OS condition is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature

tibial

tubercle. This occurs in preadolescence during a time when the

tibial

tubercle is susceptible to strain. OS condition should be distinguished from overuse of the patella-patellar tendon junction, which is referred to as

Sinding

-Larsen-Johansson syndrome (the adolescent equivalent of jumper's knee).

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Etiology

:The etiology of OS condition is controversial. Several causes have been hypothesized. The most likely

cause is that the apophysis is subject to traction during the adolescent years, which can result in microfractures

. The

tibial

tubercle

apophysis

appears in children aged 7-9 years. Usually, an

apophysis

develops proximally toward the epiphysis as the epiphysis grows distally toward the

apophysis

.

Repeated traction from the patellar tendon can cause

microfractures

in the

apophysis

.

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Clinical features:

Obtaining the individual's history and performing a physical examination are usually sufficient for the physician to make a diagnosis of OS condition.OS

condition is the most frequent cause of knee pain in children aged 10-15 years. Patients present with a history of pain inferior to the patella at the insertion of the patellar tendon. Typically, individuals report a sport or other activity that aggravates the pain, which generally is improved with rest and worsened with activity. While any activity may be involved, sports involving jumping or running are a common cause.

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Physical findings

are limited to the area of the tibial

tubercle and patellar tendon. Generally, there is a prominence and soft tissue swelling over the tibial

tubercle

.

Tenderness

of the patellar tendon may be present. The remainder of the knee examination usually is normal. Attempted flexion against resistance may produce pain. Patients may resist knee flexion because of inflammation and pain from pull on the patellar tendon. Tight hamstrings and/or quadriceps may also be noted when compared to the uninvolved side.

Imaging Studies

:

While radiographs are not essential, they usually are obtained. Radiographs show fragmentation of the

tibial

tubercle

apophysis

and, at times, a separate

ossicle

.

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TREATMENT:

Medical therapy:-Most patients respond to

conservative care that consists of rest and avoidance of the offending activity. Stretching of the quadriceps and hamstrings before engaging in athletics may be helpful. Applying ice after physical activity may decrease swelling and pain. Immobilization by casting or bracing usually is unnecessary except in severe cases.

Nonsteroidal

anti-inflammatory drugs

may be used but have not been shown to decrease the course of the disease. Steroidal injections should not be used. Other than the presence of an

ossicle

that causes pain with kneeling, there are no long-term disabilities or problems associated with this condition.

Surgical therapy:-

Surgery to treat OS condition is rarely indicated. Occasionally, adults have a large

ossicle

and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa,

ossicle

, and any prominence. Surgical treatment is rarely, if ever, indicated in children.

 

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OUTCOME AND PROGNOSIS

:OS condition has a natural history that is self-limiting. In the Krause study (1990), 90% of patients were relieved of all their symptoms approximately 1 year following onset of symptoms with conservative care. Occasionally, patients may have continued problems kneeling into adulthood or have a tender

ossicle and/or bursa that may require resection.

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Chondromalacia

patellae(patellofemoral

overload syndrome)The syndrome of anterior knee pain and patellofemoral tenderness is common among active adolescents and young adults.

Parthenogenesis:-

The basic disorder is due to mechanical overload of the

patellofemoral

joint which due to :

1-

malcongruence

of

patellofemoral

surfaces(abnormal shape of patella or

intercondylar

groove).

2-

malalignment

of the extensor mechanism or relative weakness of the

vastus

medialis

which

causesthe

patella to tilt or

subluxate

during flexion and extension.

Pathology:

Patellofemoral

overload leads to both changes in

articular

cartilage and the

subchondral

bone.

Articular

cartilage

:-

there's

softing

and fibrillation of

articular

surface of patella.

Subchondral

bone:-

there's reactive vascular

congenstion

(

apotent

cause of pain).

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Clinical features :

The patient is usually a teenage girl or an athletic young adult ,complains of

pain over the front of the knee or underneath the knee-cap. Symptom are aggravated by activity or climbing stairs, or when standing up after prolonged sitting.

The

quadriceps may be wasted

and there may be

asmall

effusion

.

Patellofemoral

pain is elicited

by pressing

the patella against the femur and asking the patient to contract the quadriceps-first with central pressure, then compressing the medial facet then the lateral. If in addition

,

the apprehension test is positive

, this suggest previous

subluxation

or dislocation.

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Imaging :

x-ray examination should include

skyline views of patella, which may show abnormal tilting or subluxation, and a lateral view

with knee partly flexed to see

if the patella is high or small.

The most accurate way of showing and measuring

patellofemoral

malposition

is by

CT or MRI

with the knees in full extension and varying degrees of flexion.

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Arthroscopy:

Cartilage softening is common in asymptomatic knees and painful knees may show no abnormality. However, arthroscopy is useful in excluding other causes of anterior knee pain

.Differential diagnosis of anterior knee pain :1-Referred from hip.

2-

Patellofemoral

disorders (patellar instability,

patellofemoral

overload,

patellofemoral

osteoarthritis,

osteochondral

injury).

3-Joint disorders (

osteochondritis

dissecans

, loose

body in the joint, synovial

chondromatosis

).

4-Periarticular disorders(patellar tendinitis, patellar ligament strain, bursitis, Osgood-

Schlatter's

disease

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Treatment:

In the vast majority of cases the patient will be helped by adjustment of stressful activities and physiotherapy

and reassurance that most patints recover. Exercises are directed at strengthening the medial quadriceps

so as to counterbalance the tendency to lateral tilting or

subluxation

of the patella.

If the symptoms persist,

surgery

can be considered-lateral release, or lateral release combined with one of the realignment procedures:

1-proximal realignment

with

vastus

medialis

reefing.

2-distal realignment

with transposition of the lateral half of the patellar ligament towards medial side or through transposition of patellar

ligment

insertion(

tibial

tubercle).other procedures like

chondroplasty

(shaving of patellar

articular

surface by arthroscopy or lastly

patellectomy

.